P - 76500REQUEST FOR ELECTRICAL INSPECTION ����
1-� �396 5 y ��% ,:�
� ❑ Minnesota Board of Electricit �- ,:��„
1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 �
' (651) 642-0800 TTY/MRS 1-800-627-3529 www.electricity.stale.mn.us �;��
Describe -using the back of the white copy if necessary - the wo covered by this request:
�t�'.Qiti� �
GENERAL FEES Outdoor Liahtina Standard (� $1
I SERViCES / POWER
Above 200 Am ere a$10
ALARM, COMMUNICATION, REMOTE CONTROL, S�G
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS
Each S stem Device or Ap aratus $.50
ADDITIONS TO THE GENERAL FEES
3 to 12 Units @$50 Per Unit
Each Additional Unit @ $25
OTHER ADDITIONAL FEES
Lighting Retrofit @ $.25 per Fi�ure
Center Pivot Irriaation Boom l� $40
Traffic Signal Standard
Supplemental Fee @ $
Transformers up to 10 I
Transformers over 10 M
ONE & TWO FAMILY DWELLINGS, EACH UNIT
Includes the Service and/or Power Supply up to 500 Amperes, All
Circuits and Two Inspection Trips Each Dwelling Unit @$80
Additiona� Inspection Trips @ $20
Investiqative Fee
IVIALhtt 9
total fee is $20) c7� � i �
I hereby certiy that I inspected the electrical installation descnbed herein on the dates stated:
Special Inspection $30 per Hour E""REO'^�^"�
Special Inspection $.31 r Mile
� THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF
`I I I I II I II II III II I I I II III I I I II II III I I III il �I I I�
19223965
Q��
12 MONTHS �_ _�
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� � Rough-in Inspedion Required? ❑ Yes �o Inspection Other Than ugh-In: � eady Now ❑ Will Call
// � � You must call the inspector when ready! Date Ready: l/ a 9 �
I certify that I am the �LICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of the electrical work at:
Job Site SVeet Address �� City ��„�%��
a a �oaUU f�Gl,OUI 5 i, ��''
Township Section Range Fire No. Counry
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OwnedOccupant Name Please Provide Two (2) Phone Numbers Including Area Code
�/%A/1i� � L�1iPls� (�� 7gs- aZ i)
Electrical Utility Electrical UGlity Address
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Contrador / Company Name Contrador License Number Master Electrician or Power Limited Technici
��Cl-/K /�i G �G'\V(c�� �AQ�/ � License O �
Mailing Address (Coniractor, Company or Ow9er Perfortning Installation) ^
a� v�/fU��S �7 � .4 ��'�YE �/��,pZ�'l � s�y��
Authorized Signature (Contrador r Owner Pe ortning Installation) Please vide Two (2) Phone Numbers InGuding Area Code
�_ 176�1s�a I� (6�)�6-c(�
INSTRUCTIONS BACK OF YELLOW COPY BOA� OF ELECTRICITY COPY
__ _ _ _ E&OOOOtA-15 8.1. 2